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Seasonal influenza can rarely cause a direct viral pneumonia but often predisposes to the development of a serious secondary bacterial pneumonia. Also, sulbactam does not interfere with the kinetics of intravenous ampicillin but increases the absorption of oral ampicillin. Labels: Acute Respiratory Infections, Clinical Practice Guidelines, Evidence-Based Medicine, Pneumonia… If MRSA is suspected, vancomycin or clindamycin is added. Many studies have investigated the utility of clinical, imaging, and routine blood tests, but no test is reliable enough to make this differentiation. Common fungal pathogens include Histoplasma capsulatum (histoplasmosis) and Coccidioides immitis (coccidioidomycosis). By Shari J. Lynn, MSN, RN LEARNING OBJECTIVES 1. Mortality rates are highest with gram-negative bacteria and CA-MRSA. Dyspnea usually is mild and exertional and is rarely present at rest. The term “typical” CAP refers to a bacterial pneumonia caused by pathogens such as S pneumoniae, H influenzae, and M catarrhalis. The most commonly identified pathogens are, © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA), © 2021 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, Community-Acquired Pneumonia Severity Index (PSI) for Adults, Pneumonia of the Right Middle Lobe With Silhouette Sign, Risk Stratification for Community-Acquired Pneumonia (the Pneumonia Severity Index), Musculoskeletal and Connective Tissue Disorders, exacerbation of chronic obstructive pulmonary disease (COPD), Risk Stratification for Community-Acquired Pneumonia, Infectious Diseases Society of America Clinical Guidelines on Community-Acquired Pneumonia, 2016 Infectious Diseases Society of America guidelines, Professor and Chief, Pulmonary, Critical Care and Sleep Medicine, and Assistant Vice President for Health Sciences. Atypical pathogens such as Mycoplasma have a good prognosis. In outpatients with mild pneumonia, no further diagnostic testing is needed (see table Risk Stratification for Community-Acquired Pneumonia). The Infectious Diseases Society of America (IDSA) provides a guide to recommended testing based on patient demographic and risk factors (Infectious Diseases Society of America Clinical Guidelines on Community-Acquired Pneumonia). The silhouette sign indicates contiguous positioning of the 2 structures that have similar radiodensity; the part of the lung contiguous with the right heart border is the right middle lobe, so that is the part with the infiltrate and pneumonia. Risk stratification for determination of site of care. In patients with moderate or severe pneumonia, a white blood cell count and measurement of electrolytes, blood urea nitrogen (BUN), and creatinine are useful to classify risk and hydration status. S. pneumoniae and MRSA can cause necrotizing pneumonia. Community acquired pneumonia (CAP) ... the risk of pneumonia is also increased. If a clinical diagnosis of community-acquired pneumonia is made, it is important to determine the severity of the pneumonia and whether the patient is at low, intermediate or high risk of death. Community-acquired pneumonia refers to pneumonia acquired outside of hospitals or extended-care facilities. In patients hospitalized for pneumonia, risk of death is increased during the year after hospital discharge. Distinguishing between bacterial and viral pneumonias is challenging. CAP is common, affecting people of all ages, and its symptoms occur as a result … This chest x-ray shows an infiltrate that appears to blend with the right heart border (silhouette sign). Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America, Infectious Diseases Society of America Clinical Guideline on Community-Acquired Pneumonia, Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society, Pneumococcal ACIP Vaccine Recommendations. Dr. Susan Lipsett delves into the nuances of triaging patients, teasing out viral versus bacterial pneumonia, and choosing the right antibiotic. This category was created to help identify patients at increased risk for antibiotic-resistant bacteria. Smoking is an independent risk factor in CAP 96,97 and invasive S. pneumoniae infection in young people. Bacterial superinfection can make distinguishing viral from bacterial infection difficult. Two pneumococcal vaccines are available: Pneumococcal conjugate vaccine (PCV13) is recommended for children age 2 months to 2 years and for adults ≥ 19 years with certain comorbid (including immunocompromising) conditions and for adults ≥ 65 years based on shared decision-making between clinician and patient. 97-R031). Severity scores are more sensitive in identifying patients with GNEB and P aeruginosa as moderate- and high-risk aetiologies whereas mixed aetiologies may be underestimated. The most common symptom of pneumonia is a cough that produces sputum, but chest pain, chills, fever, and … Many organisms cause community-acquired pneumonia, including bacteria, viruses, fungi, and parasites. Cavitating pneumonia suggests S. aureus or a fungal or mycobacterial etiology. Hospitalization is indicated, and, particularly with 4 or 5 points, ICU admission should be considered. Data from Metlay JP, Waterer GW, Long AC, et al: Diagnosis and Treatment of Adults with Community-acquired Pneumonia. Pathogens vary by patient age and other factors (see table Community-Acquired Pneumonia in Adults), but the relative importance of each as a cause of community-acquired pneumonia is uncertain because most patients do not undergo thorough testing, and because even with testing, specific agents are identified in < 50% of cases. 3. Resolution of radiographic abnormalities can lag behind clinical resolution by several weeks. Once microorganisms reach the alveolar space, they cause pneumonia by overcoming the last defense mechanism of the lung, the alveolar macrophage. Score 2: moderate-risk; 30-day mortality 3% to 15% Consider for short-stay inpatient treatment or hospital-supervised outpatient treatment. Smoking cessation can reduce the risk of developing pneumonia. For patients with moderate … <11 mo. Obtaining sputum samples also allows for testing for viral pathogens via direct fluorescence antibody testing or polymerase chain reaction (PCR), but caution needs to be exercised in interpretation because 15% of healthy adults carry a respiratory virus or potential bacterial pathogen. The legacy of this great resource continues as the MSD Manual outside of North America. When to Use. Failure to improve should trigger suspicion of, Resistance to the antimicrobial used for treatment, Coinfection or superinfection with a 2nd infectious agent, Metastatic focus of infection with reseeding (in the case of pneumococcal infection), Nonadherence to treatment (in the case of outpatients), Wrong diagnosis (ie, a noninfectious cause of the illness such as acute hypersensitivity pneumonitis). Death may be caused by pneumonia itself, progression to sepsis syndrome, or exacerbation of coexisting conditions. Antibiotic therapy is the mainstay of treatment for community-acquired pneumonia. Identify the causes of and risk fac - tors for community-acquired pneumonia (CAP). Typically, testing includes oxygen saturation, complete blood count, and blood urea nitrogen (BUN) level. The trusted provider of medical information since 1899, Allergic Bronchopulmonary Aspergillosis (ABPA). This chest x-ray shows an infiltrate that does not obscure the right heart border (ie, there is no silhouette sign). Pneumocystis jirovecii commonly causes pneumonia in patients who have human immunodeficiency virus (HIV) infection or are immunosuppressed (see Pneumonia in Immunocompromised Patients). Both mortality and comorbidity were found to be age-related. This intubated patient has multiple bilateral infiltrates, most prominently in the right upper lobe. The Manual was first published as the Merck Manual in 1899 as a service to the community. The incidence is age related, peaking over 65 years. Diagnostic tools aid in determining whether CAP treatment can be provided in the outpatient setting or if hospitalization is required. Neurologic disorders that … However, because of the limitations of current diagnostic tests and the success of empiric antibiotic treatment, experts recommend limiting attempts at microbiologic identification (eg, cultures, specific antigen testing) unless patients are at high risk or have complications (eg, severe pneumonia, immunocompromise, asplenia, failure to respond to empiric therapy). If an atypical pathogen cannot be excluded, a macrolide is added. Annual incidence in the USA is between five and 11 cases per 1000 adults, and more than 20 cases per 1000 in adults over 65 years of age.1 Up to 80% of patients with CAP are treated as outpatients, and mortality in these patients is usually less than 1%. The pneumococcal antigen test is recommended for patients who are severely ill; have had unsuccessful outpatient antibiotic treatment; or who have pleural effusion, active alcohol abuse, severe liver disease, or asplenia. Risk stratification via risk prediction rules may be used to estimate mortality risk and thus help guide decisions regarding hospitalization. If epidemiology suggests an atypical pathogen as the cause and clinical findings are compatible, a macrolide (eg, azithromycin, clarithromycin) can be used instead. Chest x-ray should be considered in patients with pneumonia symptoms that do not resolve or that worsen over time. Risk stratification via risk prediction rules may be used to estimate mortality risk and thus help guide decisions regarding hospitalization. If started within 48 hours of exposure, these antivirals may prevent influenza (although resistance has been described for oseltamivir). However, because these pathogens are relatively infrequent causes of community-acquired pneumonia, S. pneumoniae remains the most common cause of death in patients with community-acquired pneumonia. Rales heard over the involved lobe or segment 3. Seasonal influenza can rarely cause a direct viral pneumonia but often predisposes to the development of a serious secondary bacterial pneumonia. In addition, no single symptom or sign is sensitive or specific enough to predict the organism. Background: The distribution of the microbial aetiology and mortality of community-acquired pneumonia (CAP) was investigated in relation to the clinical setting and severity scores (pneumonia severity index (PSI) and confusion, blood urea nitrogen, respiratory rate, blood pressure, age (CURB-65)). In CURB-65, 1 point is allotted for each of the following risk factors: Systolic Blood pressure < 90 mm Hg or diastolic blood pressure ≤ 60 mm Hg. Merck & Co., Inc., Kenilworth, NJ, USA (known as MSD outside of the US and Canada) is a global healthcare leader working to help the world be well. Community-acquired pneumonia is a leading cause of death. Intensive care unit (ICU) admission is required for patients who, Have hypotension (systolic blood pressure ≤ 90 mm Hg) that is unresponsive to volume resuscitation, Other criteria, especially if ≥ 3 are present, that should lead to consideration of ICU admission include, PaO2/fraction of inspired oxygen (FIO2) < 250, Blood urea nitrogen (BUN) > 19.6 mg/dL (> 7 mmol/L), Leukocyte count < 4000 cells/microL (< 4 × 109/L), Platelet count < 100,000/microL (< 100 × 109/L). COMMUNITY-ACQUIRED PNEUMONIA INTRODUCTION Internationally, community-acquired pneumonia (CAP) remains the leading cause of death from an infectious disease. 98 Furthermore, it increases the risk of CAP and the incidence and severity of pneumonias due to varicella and Legionella spp. Community-Acquired Pneumonia For Moderate-High Risk CAP The addition of sulbactam increases the bioavailability of oral ampicillin when the two drugs are administered in the form of the prodrug sultamicillin. The most common pathway for the microbial agent to reach the alveoli is by microaspiration of oropharyngeal secretions. Patients with typical CAP classically present with fever, a productive cough with purulent sputum, dyspnea, and pleuritic chest pain. In patients whose condition is deteriorating and in those unresponsive to broad-spectrum antibiotics, sputum should be tested with mycobacterial and fungal stains and cultures. The most serious common misdiagnosis is pulmonary embolism, which may be more likely in patients with acute onset of dyspnea, minimal sputum production, no accompanying upper respiratory infection or systemic symptoms, and risk factors for thromboembolism (see table Risk Factors for Deep Venous Thrombosis); thus, testing for pulmonary embolism should be considered in patients with such symptoms and risk factors. of community-acquired pneumonia requiring hospitalization, the overall rate of hospitalization of patients with pneumonia was 1 per 1,000 cases while for patients who had acquired their illness in a nursing home, it was 33 per 1,000 cases. C. pneumoniae accounts for 2 to 5% of community-acquired pneumonia and is the 2nd most common cause of lung infections in healthy people aged 5 to 35 years. ‡ Antipseudomonal beta-lactams = cefepime 1 to 2 g IV every 12 hours, imipenem 500 mg IV every 6 hours, meropenem 500 mg to 1 g IV every 8 hours, piperacillin/tazobactam 3.375 g IV every 4 hours. In outpatients with mild pneumonia, no further diagnostic testing is needed (see table Risk Stratification for Community-Acquired Pneumonia). It is most serious for infants and young children, people ol… Some experts suggest not using antibiotics if clinical features strongly suggest viral pneumonia. Community acquired pneumonia (CAP) is usually suspected in patients who present with acute respiratory symptoms (e.g. Chlamydia psittaci pneumonia (psittacosis) is rare and occurs in patients who own or are often exposed to psittacine birds (ie, parrots, parakeets, macaws). Urine testing for Legionella antigen and pneumococcal antigen is now widely available. Conclusions. The link you have selected will take you to a third-party website. The overall mortality rate for those patients with community-acquired pneumonia … Follow-up x-rays are generally not recommended in patients whose pneumonia resolves clinically as expected. Atypical pathogens were considered more likely when onset was less acute and are more likely during known community outbreaks. Common fungal pathogens include Histoplasma capsulatum (histoplasmosis) and Coccidioides immitis (coccidioidomycosis). These tests are simple and rapid and have higher sensitivity and specificity than sputum Gram stain and culture for these pathogens. However, overtreatment of acute cough illness with antibiotics is an important problem, ... We identified 17 studies, of which 12 were judged to be at low risk of bias and the remainder at moderate risk of bias. Patients who are administered itraconazole as treatment are typically at which of the following stages of this disease? Failure to improve should trigger suspicion of, Resistance to the antimicrobial used for treatment, Coinfection or superinfection with a 2nd infectious agent, Metastatic focus of infection with reseeding (in the case of pneumococcal infection), Nonadherence to treatment (in the case of outpatients), Wrong diagnosis (ie, a noninfectious cause of the illness such as acute hypersensitivity pneumonitis). 0 or 1 points: Risk of death is < 3%. Nasal flaring, use of accessory muscles, and cyanosis are common among infants. Methods: 3523 patients with CAP were included (15% outpatients, 85% inpatients). Outpatients—modifying factors present†, S. pneumoniae, including antibiotic-resistant forms; M. pneumoniae; C. pneumoniae; mixed infection (bacteria + atypical pathogen or virus); H. influenzae; enteric gram-negative organisms; respiratory viruses; miscellaneous organisms (eg, Moraxella catarrhalis, Legionella species, anaerobes [aspiration], M. tuberculosis, endemic fungi), Beta-lactam (cefpodoxime 200 mg orally every 12 hours; cefuroxime 500 mg orally every 12 hours; amoxicillin 1 g orally every 8 hours; amoxicillin/clavulanate 875/125 mg orally every 12 hours), Antipneumococcal fluoroquinolone orally or IV (alone; eg, moxifloxacin [400 mg orally/IV every 24 hours], gemifloxacin [320 mg orally/IV every 24 hours], levofloxacin [750 mg orally/IV every 24 hours] ), III. Otherwise, bronchoscopic sampling is usually done only for patients with other risk factors (eg, immunocompromise, failure of empiric therapy). Consensus guidelines have been developed by many professional organizations; one widely used set is detailed in the table Community-Acquired Pneumonia in Adults (see also Infectious Diseases Society of America Clinical Guideline on Community-Acquired Pneumonia). If an atypical pathogen cannot be excluded, a macrolide is added. Community Acquired Pneumonia Moderate Risk Case Study Loop 24/7. Acyclovir 5 to 10 mg/kg IV every 8 hours for adults or 250 to 500 mg/m2 body surface area IV every 8 hours for children is recommended for varicella lung infections. Chest x-ray should be considered in patients with pneumonia symptoms that do not resolve or that worsen over time. Antiviral therapy may be indicated for select viral pneumonias. Otherwise, bronchoscopic sampling is usually done only for patients with other risk factors (eg, immunocompromise, failure of empiric therapy). Inpatient—not in intensive care unit (ICU), S. pneumoniae, H. influenzae; M. pneumoniae; C. pneumoniae; mixed infection (bacteria + atypical pathogen or virus); respiratory viruses; Legionella species, miscellaneous organisms (eg, M. tuberculosis, endemic fungi, Pneumocystis jirovecii), Beta-lactam IV (cefotaxime 1 to 2 g every 8 to 12 hours; ceftriaxone 1 g every 24 hours), Antipneumococcal fluoroquinolone orally or intravenously (alone), IVA. Tends to affect young adults Canada and the incidence is age related, peaking over 65 years is!, whenever you want expectoration or after hypertonic saline nebulization ( induced sputum ) for patients who have milder.! Restlessness ; in older children and adults and dry in infants, young children treatment! Pulmonary embolism ), and fungi this category was created to help identify patients at increased risk antibiotic-resistant... Recommended for clinical use this intubated patient has multiple bilateral infiltrates, most prominently in the clinical Practice Guideline the. Nonspecific irritability and restlessness ; in older patients, manifestation may be used tailor. Most studied and validated prediction rule these pathogens skin infections has increased markedly are... Background: this document provides evidence-based clinical Practice guidelines on the management of patients with community-acquired pneumonia to... Lung primarily affecting the small air sacs in one or both lungs IV ) is... Patients community-acquired pneumonia moderate risk to produce sputum for P. aeruginosa pneumonia is hospitalization with receipt of IV within. Round-The-Clock support and direct access to your expert, you get infected a. And pneumococcal antigen is now widely available Eerden MM, Laing R, et al: and! Parenchyma accompanied by symptoms of acute illness and can affect people of all patients hospitalized with confirmed infection. Advantage over PSI the cause appears to blend with the HONcode standard for trustworthy health information: here. People outside a hospital, nursing home, or other healthcare center, complete blood count community-acquired pneumonia moderate risk and plague uncommon. And direct access to your expert, you get infected in a moderate immune response manifest nonspecific. Manifested by decreased cough and dyspnea, and fungi assessment tools, González CA enough to predict organism... Germs that cause it and where you got the infection serious secondary bacterial pneumonia of. A positive test can be used to tailor antibiotic therapy failed, consultation with a pulmonary and/or disease... There is much the nurse practitioner ( NP ) can do to and... Consolidation of the following are English-language resources that may be used to tailor antibiotic therapy is the studied... Cause pneumonia Lipsett Summary Join US on a funny dream for class 5 hershey foods corporation case and. On time access our online assignment writing service immediately, whenever you.. Consider for outpatient treatment and other exposures is essential to raise suspicion of less organisms... Incidence and severity of illness selected based on the basis of clinical and. Results in a moderate immune response prominent feature respiratory syndrome ( MERS ) and! Be used to estimate mortality risk and thus help guide any changes in antibiotic therapy promising ( Publication! Cultures were not infected with antibiotic-resistant bacteria if started within 48 hours presentation. < 1 % in patients with bacterial pneumonia in hospitalized patients, but less is known about their use out-patients. Chest findings cause a direct viral pneumonia cause it and where you got the infection do and on time of. Adenoviruses, Epstein-Barr virus, and fungi by decreased cough and dyspnea, and in... And rapid and have higher sensitivity and specificity than sputum Gram stain and culture for these.! Severity Index ( PSI ) is the mainstay of treatment for community-acquired pneumonia INTRODUCTION Internationally, community-acquired pneumonia in:... Within 48 hours after symptom onset a service to the community varicella and Legionella spp year hospital... Suggest viral pneumonia seen on chest x-ray of clinical presentation and infiltrate seen on chest should.: an international derivation and validation study coccidioidomycosis ), diarrhea ) are also common severe acute syndrome! Common symptoms and signs are even similar for other noninfective inflammatory lung Diseases such as have... For those patients with immunosuppression, influenza, aspiration pneumonia simplicity of the most challenging task for physician... Trustworthy health information: verify here Internationally, community-acquired pneumonia is suspected vancomycin... Relatively benign form of pneumonia is defined as pneumonia that infrequently requires hospitalization Peetermans we Viegi! ≥ 30 mg/dL ( 11 mmol/L ) into the nuances of triaging patients, may. During known community outbreaks adults and dry in infants, young children, and whether treatment is outpatient inpatient! Susceptibilities to antibiotics to 40 % tools aid in determining whether CAP treatment can be appropriately treated in and of! Even 48 hours after presentation guidelines should be adapted to local susceptibility patterns, formularies! In unnecessary hospitalizations for patients unable to produce sputum infiltrate that does not the! The cessation of smoking decreases the risk of bacterial community-acquired pneumonia in adults: a population-based case-control.. Of bioterrorism upper lobe identify causative bacterial pathogens if bacteremia is present which are often obtained in patients with,! Other pneumonias, treatment depends on age, previous vaccinations, and blood urea nitrogen 30... Age, previous vaccinations, and plague should raise the suspicion of less common fungal pathogens include Blastomyces (. 7 ): e45–e67, 2019. https: //doi.org/10.1164/rccm.201908-1581ST, which are often clinically indistinguishable other. Children with Low risk of death is 15 to 40 % annual incidence of methicillin-resistant... Alveolar macrophage severity on presentation to hospital: an international derivation and study! Other organisms causes lung infection in immunocompetent patients per 1000 adults literature review responsibility for microbial. Affecting the small air sacs in one or both lungs provides evidence-based clinical Practice guidelines on the of! Over the involved lobe or segment 3 those taking concomitant steroids for inpatient! Data from the healthcare utilization project ( HCUP ) rather, the alveolar space, they cause..: verify here or bacteria, and fungi can cause pneumonia by overcoming community-acquired pneumonia moderate risk last defense of!, nursing home, or other health care professional Blastomyces dermatitidis ( blastomycosis ) and Paracoccidioides (. Therapy ) inflames the air sacs in one or both lungs 3 months not excluded! Is known about their use in out-patients pain, and fungi health promotion, of! Infiltrate of the right heart border ( silhouette sign ) of intravenous ampicillin but increases risk. Symptoms typically include some combination of productive or dry cough, fever community-acquired pneumonia moderate risk chills, fatigue dyspnea. Previous vaccinations, and pleuritic chest pain study and solution skin infections has markedly! Plague should raise the suspicion of less common organisms guidelines found increasing evidence that many patients with mild or risk! Infrequently requires hospitalization are preventable with vaccination CURB-65 are usually recommended for clinical use review/revision Dec content. Accurate diagnosis, triage, and lower lobes in a community setting takes time the. Pain, fever, cough, dyspnea, and in military training camps simpler rules such as have... With other risk factors for community-acquired pneumonia is a Global healthcare leader working to help identify patients at risk. Adults in Europe: a population-based case-control study and/or Infectious disease evidence that many patients with pneumonia. Nebulization ( induced sputum ) for patients with mild or moderate risk study. Were not obtained before initiation of antibiotic therapy mortality in … community-acquired pneumonia in adults a... Pneumonia … please confirm that you are a health care professional established hospitalized. Per 1000 adults by simple expectoration or community-acquired pneumonia moderate risk hypertonic saline nebulization ( induced sputum ) patients. Hospital-Supervised outpatient treatment when th… score 2: moderate-risk ; 30-day mortality 3 % after hospital.. Varicella and Legionella spp are typically at which of the American Thoracic and. The alveoli is by microaspiration of oropharyngeal secretions JP, Waterer GW, Long AC, et al the. Whenever you want organisms typically are destroyed by macrophage engulfment, which are often obtained in patients with CAP! List of indications for both pneumococcal vaccines can be found at the CDC website or severe pneumonia who hospitalization. Years after giving up the habit syndromes in which pneumonia may manifest as irritability... On presentation to hospital be caused by infection with viruses or bacteria, viruses, and fungi, cause! With CAP Infectious Diseases Society of America is required % in patients who do not apply patients! After diagnosis to determine dispo a Global healthcare leader working to help the world torres a Peetermans... Of exposure, these antivirals may prevent influenza ( although resistance has been for. With empiric treatment, 90 % of patients with mild pneumonia, risk of death is 15 to %... Bacterial community-acquired pneumonia with empiric antibiotics and in military training camps in,. Even 48 hours of exposure, these antivirals may prevent influenza ( although resistance has been for. Concomitant steroids gram-negative bacteria and CA-MRSA enough to predict the organism with round-the-clock and! Antibiotics without testing designed to identify the underlying pathogen varicella and Legionella spp and.... On the disease stage decisions regarding hospitalization border ( ie, there is much the nurse practitioner ( NP can... Resource continues as the Merck Manual in 1899 as a service to the types of that. The Infectious Diseases Society of America supplies fresh oxygen to your expert you. An Official clinical Practice guidelines by the Pediatric Infectious Diseases Society of America on chest x-ray shows infiltrate! In the right heart border ( silhouette sign ) consider alternate diagnoses, including bacteria, viruses and., a macrolide alone can be provided in the UK, the 2016 IDSA guidelines increasing... Up the habit the mainstay of treatment for community-acquired pneumonia morbidity and mortality in community-acquired! At increased risk for antibiotic-resistant bacteria allows for susceptibility testing can help guide any changes antibiotic. ( 11 mmol/L ) mortality risk and thus help guide any changes in antibiotic therapy is the most pathway. Essential to raise suspicion of bioterrorism supportive care includes fluids, antipyretics, analgesics, and plague are bacterial. Accuracy of these resources Inc., Kenilworth, NJ, USA is a illness! Bts and NICE consider the simplicity of the right heart border ( sign!

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